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A client with a history of cardiac problems is having severe chest pain. What should be nurse's first response?
- A. Notify the physician
- B. Administer an analgesic to control the pain
- C. Assess the client's pain
- D. Start oxygen at 2L minute via nasal cannula
Correct Answer: C
Rationale: Assessing the client's chest pain is the first step to determine its nature and severity, guiding further actions like notifying the physician or administering oxygen or analgesics.
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The registered nurse is observing a new nurse auscultate the breath sounds of a client. Which action by the new nurse should lead the registered nurse to determine that further teaching is needed?
- A. Uses the bell of the stethoscope
- B. Asks the client to sit straight up
- C. Places the stethoscope directly on the client's skin
- D. Encourages the client to breathe slowly and deeply through the mouth
Correct Answer: A
Rationale: The bell of the stethoscope is not used to auscultate breath sounds. The client ideally should sit up and breathe slowly and deeply through the mouth. The diaphragm of the stethoscope, which is warmed before use, is placed directly on the client's skin, not over a gown or clothing.
When developing the plan of care for a 14-year-old boy with a nursing diagnosis of Deficient diversional activity related to immobility, which of the following activities is most appropriate?
- A. Playing a card game with a boy the same age.
- B. Putting together a puzzle with his mother.
- C. Playing video games with a 9-year-old.
- D. Watching a movie with his younger brother.
Correct Answer: A
Rationale: A peer-based activity like a card game promotes social interaction and engagement, suitable for a 14-year-old's developmental needs.
Based on the fact that you family unit client is experiencing a situational crisis that has led to dysfunctional communication within the family unit, you have recommended that the entire nuclear family and members of the extended family who live in the family's home begin family therapy. The grandparents tell you that it is their grandson, rather than their son, who is addicted to prescription painkillers, is the cause of the problem; therefore, they do not have to participate in this group therapy. How should you respond to these grandparents?
- A. You should try to come to a few sessions at least because they may be very informative to you'.
- B. You are probably correct. This really is not your problem'.
- C. Despite the fact that it is your grandson's drug addiction, situations such as this affect all members of the family including grandparents who live in the home.'
- D. You should attend because the doctor has ordered family therapy for you as extended family members'.
Correct Answer: C
Rationale: Addiction affects the entire family system, including extended family members living in the home. Their participation in therapy can help address dysfunctional communication and support the family unit as a whole.
A client who has glaucoma has been prescribed timolol (Timoptic) eyedrops. Which of the following instructions should the nurse give the client about the administration of the eyedrops?
- A. Instill the eyedrops whenever the eyes feel irritated
- B. The medication may cause some transient eye discomfort
- C. Keep the medication refrigerated between doses
- D. The need to use the eyedrops will be reevaluated after 1 month
Correct Answer: B
Rationale: Timolol eyedrops may cause transient eye discomfort, such as stinging or burning, which is a common side effect. Instilling drops only when eyes are irritated is incorrect, as timolol requires regular dosing. Refrigeration is not necessary, and reevaluation timing depends on the physician's plan, not a fixed month.
An adolescent tells the school nurse she thinks she has infectious mononucleosis. The nurse should next assess the client for?
- A. Sore throat and malaise.
- B. Fatigue and weight loss.
- C. Coldlike symptoms and fever.
- D. Skin rash and abdominal pain.
Correct Answer: A
Rationale: Sore throat and malaise are hallmark symptoms of mononucleosis, requiring targeted assessment.